ML20155F766
| ML20155F766 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 07/25/1996 |
| From: | Brinckman C, Duda D, Urban M PENNSYLVANIA POWER & LIGHT CO. |
| To: | |
| Shared Package | |
| ML20155F723 | List: |
| References | |
| FOIA-98-81 739619-96, NUDOCS 9811060110 | |
| Download: ML20155F766 (8) | |
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n~ . ~ mv.gyl l July 25,1996 Corporate Audit Services (Auditing) conducted a review of the June 14,1996 at the Susquehanna Steam Electric Station (SSES)(. circum . The primary objective of our review was to inde )endently evaluate the possibility of tam xring as it relates to the failure to discover t le Misahanment in a the wrong breaker while erforming a routine job function which r)esult Misalignment. During period between June 14 and July 4,1996, three surveillances conducted by 3 different POs failed to discover the Misalignment. Our review centered upon the rehability of these three surveillances and the possibility that the Misalignment could have been purposely concealed. A Plant Event Review Team (ERT) and Independent Safety Evaluation Services (ISES) are each conducting reviews of the event. EXECUTIVE
SUMMARY
l In our opini it is unlikely that the Misalignment was or that someone tampered)th the E Diesel breaker between June 1[an fulf 4,1996. el concealed f in the absence of collusion, an individual would have had to purposely correct the Misalignmentjus ri r to a June 20 surveillance and then re set it in the improper position after a h eillance was complete. We found no evidence to.suggest . these circumstances. We.believe that human error, NPOs, is the. reason the Misalignment remam,in ed undetected fromparticular June 14 until inattentiveness July 4, to de 1996. We base this conclusion upon the following facts: e One NPO admitted that his surveillance results may not have been accurate. There is also evidence which suggests that he conducted his surveillance too quickly to be effective.
. A second NPO had past perform, whomassociated ance >roblems we were withunable to interview inattentiveness to during our re detail and performing sis work too quickly.
. A third NPO admitted he did make a mistake while performing his surveillance of the T Diesel. The NPO observed signs of a problem with the T Diesel breaker but after assessing the situation, he
' convinced himself that no problem existed. Subsequently, the NPO realized be made an error mjudgment.
in particular the
. . NPOs ence expressed of steps to beconcern performed)about the confusing of the diesel electr format (ical surveillanc (S 100 005 procedure used as a guide to perform the surveillance and for docum)entation of results.
- Nuclear Operations does not require periodic supervisory participation for the inspection process of the diesels. This control is utilized m many other similar inspections throughout SSES.
. NPOs indicated they were ' comfortable' with the diesel electrical surveillances and did not expect to find any problems.
EX B1T i PAGE _0F1PAGE(S)
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'It may be appropriate to review the applicable procedures and training to determine the extent, if any, to which they contributed to the NPOs' overall performance.
Additional support for our opinion and details of Auditing's Action Plan I follows. BACKGROUND Highlights of the Misalignment events are as follows: e On June 14,19%, NPO #1 was assi; ped to perform a swap of the T Diesel for the 'D' Diesel. When t2e Misalignment was discovered and shown to NPO #1 he realized and agreed that he had moved the wrong breaker, thu,s resulting in a uusalignment of the' Diesel, e On B, NPO #2 merformed a scheduled electrical
'surve ance o te T Diesel and did not discover any alignment e NPO #3 wrformed a scheduled electrical surveillance of the T Diese: and did not discover any alignment problems.
e , NPO #4 performed a scheduled round which has a suspected a problem with the T Die)sel breake
.. he did not have time to investigate the problem that night. .
. On NPO #5 performed a scheduled electrical i
s ance o e T Diesel and observed signs of a problem with the T Diesel breaker. However, after assessmg the situation, he convinced himself that no problem existed.
. . , NPO #4 performed a scheduled round in the T Di an upon closer inspection of the T Diesel breakers, discovered the Misalignment.
Initial interviews with NPO #2 and #3 ebnducted by the ERT Team (which 1996 indicated that these NPOs believed their surveillances were was formedonanJul properly 5,d the ) breakers were properly ali ped. Inconsistencies betweer the results o surveillances and the subsequent rount perfonned by NPO #4 raised the possibility of tampering. ACTION PLAN '
< In performing our investigation, Auditing took th'e following actions:
l - met with the ERT Team to obtain background information l reviewed associated condition reports evaluated overtness, intent, and sophistication of this inc_ident EX LEIT v -. -
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collected and reviewed othe'r relevant documentation including: surveillance reports, plant logs, performance evaluations and trauung recorcfs conducted a walkdown of the T Dicsel building observed a mock surveillance /round of the T Diesel building identified individuals who were directly related to events occurring i from the time the Misalignment occurred until discovered and corrected interviewed employees directly related to the Misalignment interviewed other employees who were in the T Diesel building during the Misalignment period i reviewed wor'; authorizations associated with equipment #0A510 (T Diesel breaker panel) reviewed labeling changes on the OA510,T Diesel breaker panel Evaluation of Tampering as a Root Cause 7 3,. We believe the possibility of tampering is unlikely based on the following
- - w
. NPO #1 admitted to making the mistake which resulted in the Misalignment on June 14,1996.
. NPO 42 admitted that his surveillance results may not have been accurate.
. NPO #5 admitted to observing a problem with the breaker alignment. ,
e In the absence of collusio an individual would have had to purposely correct the Mi 'gnment surveillance and then re-set it inimproperthe.justposition prior to a June after a 20 , June 27 sarveillance was complste.
. We did not find'any evidence to indicate that anyone intentionally; performed any activity which would result in two of the three surveillances not discovering the Misaligmnent (i.e., intentionally correcting the error prior to the first and/or second surveillance and subsec uently re establishing the Misalignment prior to the third survellance),
e The majority of NPOs interviewed told us they were not fully aware of the control room alarms associated with the T Diesel breakers or the consequences of making the breaker movement, and thus would not have been confident of their ability to correct the Mitalignment undetected.
. During our interviews we found no evidence ofintent to cause harm (i.e., explicit or implicit threats of tampering).
. During our interviews of personnel accessing the T Diesel building between June 14,1996 and Jul 4,1996, no one indicated observing or having knowledge of unusu activity within the T Diesel building.
IX MT PAGE OF 7 PAGE(S)
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N"% j Evaluation of Human Performance Factors as a Root Cause We believe that human error by NPOs is a more likel cause of the electrical surveillances not discovering the Misalignment based on the following: MURVEILLANCE PERFORMED BY NPO #2 ! Although NPO #2 initially claimed he did this surveillance accurately, he did admit to us that he "could have screwed u 2" (in regards to ' g the surveillance). Records indicate that his surveilance was comp d in 2 minutes and 11 seconds. Based upon our interview of knowle able SSES personnel and
;grformance of a mock / test surveillance, we teame that it takes approximately 8, minutes o properly complete such a surveillance. NPO #2 also told us that once you net
, ou really don't have to read each label in orde'r to ! accustomed to the surveillance, complete the surveillance. NPO y#2 also told us that he stood by cubicle
- panel OA510 and looked down the row for indicator li ts his surveillance. He said he didn't "need hands on" ysically check th reaka indication on lights". An SSE ofinstruction trains NPOs)to p oucheck sically havetheproper i
breakers in order to verify they are racked-in. NPO #2 also told us t if ever gis normal as usual and in spec) he documents equipment status on his way to ano er , location. We be leve that proper protocol would have an NPO document the equipment
- status concurrent with his observation, thus reducing the chance for error.
NPO #2 did not pay attention to detail andBased on athe t did not conduct t above facts, we be Nb electrical surveil.ance of the T Diesel on M SURVEILLANCE PERFORMED BY NPO #3 7
- We were unable to verify the reliability of NPO #3's surveillance (which
! was performed on night shift based on the fact that he was unavailable for us to interview. However we did rform attemative audit procedures that raise some questions about the r,eliabili of his surveillance report. We reviewed NPO #3's past
. performance evaluations an interviewed . supervisors. Despite the fact that his most 4 recent rmance evaluation did not in ate any performance ems, we learned < that #3 has had problems with inattentiveness to detail and wrformmg work too quickly in the recent past. In addition, NPO #3 was previ acedin the usible i Behavior Program for a failure to use a procedural c in hand, supervisor commented that most o y#3's problems or errors occurred when he was working night shift. Altho NPO #3 did receive breaker training in February 1995 our review i of certain T Diesel sker trau' u'ng data indicated that NPO #3 did not receiv,e revised I OA510 breaker racking training in the 4th Quarter 1995. - Based on the above facts in combination with the results of our interviews conduct an accurate surveillance.),We understand that Nuclear Operations interview this NPO prior to his return to duty. EX IT PAGE OF 8 PAGEIS)
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=. x URVEILLANCE PERFORMED BY NPO #5 NPO # 'ted he made a mistake while performing his surveillance of l
l the 'E' Diesel on breaker panel to R Specifically, he stated that he did not open the OA51005 t the breaker was in the proper position. He also told us that he b I had observed'.fignre hat he tho t could be a problem with that bre but after assessing the situation, he convince himself that no problem existed and h did not no the control room. This NPO was relatively inexperienced in performing this parti ular surveillance and told us that this was only the third time he had done it. He told us he had difficulty following the surveillance procedure and that this contributed to his mistake. . When questioned by a shift supervisor after the Misalignment was discovered, NPO #5 immediately realized he made an error in ' t during his
. surveillance. He stated that he concluded too quickly that no pro existed. He also stated that he did not see the instructions on the surveillance verify that the OA51005 breaker was in the proper position. procedure requiring h OTHER FACTORS In addition to the above information, we believe there are other factors indicating the existence of human performance problems associated with NPOs not paymg attention to detail. Certain reoccurring t2 emes surfaced during our interviews. "
These included:
. More experienced NPOs werFFnerally ' comfortable' with the 'E' Diesel surveillances and did not expect to find any problems.
e ' UtIer NPOs expressed concern about the confusing format (in particular the sec uence of steps to be performed oTthe diesel electrical surveil:ance h is used by NPOs as a guide to ocedure (SO.100-005)d for documentatio rm the surveillance an ofresults. .
. Nuclear Operations does not require periodic supervisory parti,cipation for the inspection process of the diesels. This control is utihzed in many other similar inspections throughout SSES.
ACKNOWLEDGMENT We wish to acknowledge the assistance that Nuclear Department personnel provided to us durms our review. If you need additional information or would like clarification on any items contained in this report, please feel free to contact us. . l Corporate Audit Services g r
'EX)ilBIT PAGE W-OF S PAGEIS)
ED 1 conndential
._ , o August 16,1996 Mr. K. V. Chambliss:
Re: Sunplement to Investigation of'E' Diesel Breaker Misalignment Report At the time Corporate Audit Services issued our report entitled
" Investigation of'E' Diesel Breaker Misalignment"(dated July 25,1996 - Job
#739619 96), we were unable to interview one of the NPGs (NPO #3) who performed Surveillance and Rounds of the 'E' Diesel Generator Building.
l l However, on July 29,1996, we interviewed NPO #3 to determine the circumstances surrounding hisWSurveillance and Rounds of the 'E' Diesel Generator Building in which he did not detect a breaker misalignment. Following are highlights of our interview with NPO #3: At the start of the interview, NPO #3 was confident that he had properly conducted the Surveillance & Rounds onM. However,later in the interview he indicated that potential tampering or a mistake on his part (inspecting b (, the wrong breaker) are two reasons why his Surveillance did not detect a breaker misalignment. In his opinion, each possibility had an equal probability of being the cause. Near the close of the interview, he indicated there was a 60-70% chance that he could have made a mistake by inspecting the wrong panel in conducting his Surveillance. A,lthough NPO #3 stated it typically takes him 10 - 15 minutes to do Surveillpce and Rounds of the 'E' Diesel Generator Building, security access data 9{ indicates he performed theMSurveillance and Rounds in approxi tnately 5 minutes. The results of this interview did not change our overall report con'clusion that it is unlikely that someone tampered with the 'E' Diesel breaker. We base this conclusion on the facts described in the aforementioned report. We believe that human error is the reason the misalignment remained undetected from June 14 O untii Juir 4,1996. EgBIT EB PAGE / OF1PAGE(S) l ._
OCT-21-95 MON 3:06 PM PFL NUC LICENSING F AX NO. 6107747540 F. 3 . .~ ,
@ Please note that on July 30,1996, Auditing informally cornmunicated the results of this interview to you.
If you need additional information or would like clarification on the interview results, please feel free to contact me at ETN 220-4801. mmh. Martin F. Urban Corporate Audit Services cc: G. J. Kuczynski F. A. Long R. G. Byram ;,., w ,. R. J. Grey G. T. Jones M. E. Kroboth
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